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U 51 NDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page 5 of 6) XII . LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOT installed . (Do not complete this section.) y N NA This section must be completed if LLDs are installed. Was a leak simulated to verify LLD performance ? ® ❑ ❑ (Check all that apply.) Simulated leak rate verified : ® 3 GPH ❑ 0 . 1 GPH ❑ 0.2 GPH Was the testing apparatus properly calibrated ? ® ❑ ❑ I W1 For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected? r[E] ❑ For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected? ❑ ❑ For electronic LLDs, does the turbine automatically shut off when a leak is detected? ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? 1 17 ❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ ❑ For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks? ❑Were all items on the equipment manufacturer's maintenance checklist completed? ❑ ❑Were all LLDs confirmed operational within regulatory requirements? ❑ ❑ For any answer of "N" above, describe in Section Xlll how and when these issues were or will be corrected. XIII , COMMENTS XIV. VACUUM / PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING ® Check this box if VPH monitoring is NOT used . (Do not complete this section.) This section must be completed if VPN monitoring is used to perform leak detection monitoring. System Type (Mark all that apply. ) ❑ Vacuum ❑ Pressure ❑ Hydrostatic j Sensor Functionality Interstitial Communication [ Sensor ID Component(S) Monitored By This Sensor Test Test ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ElPass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass [:] .Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified? ❑ Simulated Leak at Far Ends of the Interstitial Space ❑ Visual Inspection ❑ Other Describe the method in section XV below.) ❑ Gauge Was the vacuum or pressure restored to operating levels in all Interstitial spaces? ❑ Yes ❑ No (Describe the reason in section XV below.) For any answer of "Fail" above, describe in Section XV how and when these issues were or will be corrected. XV, COMMENTS GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = VacuurrWressureMydrostatic, ID = Identification ii